• Was there a witnessed or suspected direct blow to the head or a blow elsewhere on the body with an ‘impulsive’ force transmitted to the head?
• Are there acute signs and/or symptoms of concussion?

• Thorough history: Injury specifics, subsequent injury course, health history, comorbidities and mental health history including prior concussions or other TBI, which might require specialty referral. (see below)
• Examination: Neurological exam as well as standardized evaluation of post-concussive symptoms, balance, and cognition. Consideration should also be given to autonomic, oculomoter and vestibular exams. (Note: Imaging is unlikely to provide diagnostic information for concussive injuries.)

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• Provide education, reassurance and resources (e.g., what to look out for and what to expect for parents & schools).
• Encourage initial period of rest (some hours to a few days) until patient is able to tolerate light cognitive activity.
• Remove from physical activities until all concussion-related problems resolve (e.g., organized sports, physical education, physical play at recess, recreational sports) If asymptomatic review the following step entitled "Have all of the following occurred?".
• After the initial rest period, encourage steady progressive return to school (with academic adjustments as needed) as long as symptoms do not significantly worsen. Academic and home adjustments should account for cognitive and physical rest to assist in recovery.
• Re-introduce cognitive, social and cardio activity (safe, sub-symptom threshold aerobic activity under close supervision). Return to Activity differs from the progressive Graduated Return to Sport and it is not intended to take the place of the Graduated Return to Sport.

• Concussion symptoms resolved (per school, student and parent).
• Clinical exam is normal.
• No longer requiring medication for management of concussion symptoms.
• No longer requiring academic adjustments.

With this stepwise progression, the athlete should continue to proceed to the next step if free of symptoms at the current step. There should be a 24 hour period between each step. If any symptoms reoccur, the athlete should drop back to the previous step and try to progress again after 24 hours of rest. This progression should be routinely monitored by an appropriate health care provider with final CLEARANCE being made by such provider.
(Modified from Berlin Guidelines 2016)

• Light aerobic exercise such as brisk walking or stationary cycling for 15-20 minutes.
• Sport specific exercise such as skating in hockey or dribbling in soccer with minimal resistance from other players for 30-45 minutes.
• Non-contact practice with the addition of resistance such as blocking pads in football for 1-2 hours.
• Full contact practice. An example would be full pads and contact in hockey or football practice.
• Competitive gameplay including tournaments.